American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

New Crucial Literature: The Science You Need to Know

Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the Bulletin Brief editorial board.

JACS Highlights

Articles Discuss Western Washington State's Success in Effectively Responding to COVID-19

Mitchell SH, Bulger EM, Duber HC, et al. Western Washington State COVID-19 Experience: Keys to Flattening the Curve and Effective Health System Response. J Am Coll Surg. Sep 2020;231(3):316-324 e1.

Capella J. Regional Teamwork Key to Successful COVID-19 Response. J Am Coll Surg. 2020;231(3):324-325.

This article describes the development and implementation of a regional collaborative plan to respond to the public health challenges of the COVID-19 pandemic. The authors reported results of a consensus panel evaluation of the early outcomes of this plan. Six key themes were emphasized in the article, including early communication and coordination among stakeholders, regional coordination of the health system response, rapid development and planned access to COVID testing, proactive management of long-term care and skilled nursing facilities, proactive management of vulnerable populations and effective physical distancing in communities.

Distribution of COVID patients needing hospital admission was coordinated by the County Disaster Medical Control Center initially, and the success of this coordinating center led to the development of a regional COVID Coordinating Center. The major resultant accomplishment was that no health care facility was overwhelmed by COVID patients. The consensus panel produced a list of key recommendations that can be used by other regional systems. The recommendations stressed the importance of regional command centers, good communication and the use of academic medical institution laboratories to develop testing capability. The article contains useful process charts that outline the implementation plans. The approach includes many of the characteristics of the regional command centers proposed by the ACS Committee on Trauma to manage mass casualty events.

In the editorial that accompanied the article, Capella stressed the importance of team structure, situational awareness, mutual support and leadership as factors contributing to the success of programs such as the one described in the article. She emphasized that these factors are familiar to surgeons and that surgeons can play pivotal roles in leading and supporting these responses.

Pediatric Surgery Countermeasures to COVID-19 in Seattle Children's Hospital Explored in Special Article

Parikh SR, Avansino JR, Dick AA, et al. Collaborative multidisciplinary incident command at Seattle children's hospital for rapid preparatory pediatric surgery countermeasures to the COVID-19 pandemic. J Am Coll Surg. Aug 2020;231(2):269-274 e1.

Parikh and coauthors described the successful responses to the COVID-19 pandemic that resulted from a pre-existing incident command structure in a single children's hospital. The children's health system where the plan was developed serves a regional population of 11 million. The authors noted that children comprise 1 percent to 2 percent of the population testing positive for the COVID virus. Data cited in the article emphasize the importance of children in the spread of the virus through fecal and oral means.

The authors noted that the most important features of their response were an organized incident command structure that had components dealing with clinical operations, logistics, planning, finance, patient safety and communication. These groups met frequently and interacted with each other on a regularly scheduled basis. The issues that emerged as critical to the successful response to the COVID-19 pandemic were the effective incident command structure, adequate supply and conservation of personal protective equipment, workforce safety, surgical and ambulatory triage and education of residents and fellows.

Informative charts provided in the article supplied descriptions of their methods of managing emergent and non-emergent surgical cases and for control of transmission during aerosol-generating procedures. Measures that they found helpful for maintaining and improving resident and fellow education included increasing didactic lectures, increasing use of telehealth, simulation exposure and participation in national webinars.

New Study Reveals Disturbing Surge in Violent Injuries during Stay-at-Home Orders

The social isolation brought on by stay-at-home orders issued in the early phase of the COVID-19 pandemic may have a deadly and dangerous side effect: an increase in intentional penetrating injuries, especially firearm violence, that has remained at high levels even as stay-at-home orders have subsided and as COVID-19 cases are on an upswing. A new "in-press" study, published online ahead of print on the website of the Journal of the American College of Surgeons, "Increased Firearm Injury During the COVID-19 Pandemic: A Hidden Urban Burden," details this disturbing trend at a Level 1 adult trauma center in Philadelphia, PA, since the stay-at-home order was enacted on March 16, 2020.

The analysis found significant differences in trauma trends in three key demographics between post- and pre-SAHO: a higher proportion of men presenting for trauma, with men accounting for 64.4 percent of cases before SAHO and 72.1 percent after (p=0.019); more younger patients presenting, with the mean patient age of 47.4 (range 22.1 years) before and 42.9 (range 20.3 years) after (p=0.009); and a higher proportion of non-white trauma patients, accounting for 69.5 percent before and 77.7 percent after (p=0.008). Specifically, the proportion of visits for gunshot wounds nearly doubled, from 12.6 to 22.9 percent (p<0.0001).

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Other Articles

Gum Chewing Found to Be Effective in Reducing Incidence of Postoperative Ileus

Roslan F, Kushairi A, Cappuyns L, Daliya P, Adiamah A. The impact of sham feeding with chewing gum on postoperative ileus following colorectal surgery: A meta-analysis of randomised controlled trials. J Gastrointest Surg. Nov 2020;24(11):2643-2653.

The authors conducted a systematic review of the literature to determine the amount and strength of evidence supporting the use of gum chewing as a means of preventing and managing postoperative ileus after colorectal procedures. The main outcome measure evaluated was the incidence of postoperative ileus; other outcomes included time to passage of flatus, time to defecation, length of hospital stay, and mortality. Sixteen trials including nearly 1,000 patients were evaluated.

The incidence of postoperative ileus was significantly reduced with the use of gum chewing. Time to passage of flatus and time to defecation were also significantly reduced and there was no increase in hospital stay or mortality. The authors concluded that the use of gum chewing was effective and should be included in enhanced recovery pathways.

Special Article Suggests that Hydration May Alleviate Symptoms of Lower Extremity Claudication

Parodi JC, Fernandez S, Moscovich F, Pulmaria C. Hydration may reverse most symptoms of lower extremity intermittent claudication or rest pain. J Vasc Surg. Oct 2020;72(4):1459-1463.

A prospective trial on the use of measured hydration to reverse lower extremity claudication involving 132 patients was reported in this article. The authors noted that dehydration and resultant reduction in intravascular volume is common in elderly patients. These changes could reduce blood flow to extremities affected with significant arterial occlusive disease. The included patients all had severe claudication or rest pain that had not responded to measures such as exercise, control of risk factors and medication. The participants were asked to drink 2500 mL of fluid a day and to ingest 0.6 g/kg of albumin daily. Total salt in this regimen was 3.5 g/day. Skin temperature, ankle-brachial index, serum albumin concentration and time and distance to claudication were measured before starting treatment and at six weeks and six months after treatment began.

The intake goals were achieved in 131 of the 132 patients. Significant improvement in all measurements was recorded at six months after beginning treatment. The authors concluded that a program of hydration and albumin intake was helpful in patients with severe claudication and/or rest pain. Although it would have been helpful if the authors had included advice on the management of associated diseases such as hypertension and congestive heart failure during the program, the data reported suggest that this approach deserves additional study.

Mask Wearing Not Associated with Hypoxia, Small Study Finds

Chan NC, Li K, Hirsh J. Peripheral Oxygen Saturation in Older Persons Wearing Nonmedical Face Masks in Community Settings. JAMA. October 30, 2020.

One of the reasons cited for non-use of masks as a means of reducing risks of COVID-19 transmission in elderly individuals with medical comorbidities is the perceived increased risk of hypoxia as a result of mask wearing. Chan and coauthors measured oxygen saturations in 25 patients (mean age 76.5 years); medical comorbidities were present in 36 percent of patients. A standard, disposable, non-medical mask was used by all patients.

Oxygen saturations were measured one hour before, during one hour of wearing and normal activity and one hour after mask wearing was discontinued. The mean oxygen saturation before mask donning was 96 percent and remained unchanged during and after mask wearing. No patient recorded an oxygen saturation below 92 percent. The authors concluded that this evidence, although drawn from a small sample, suggested that mask wearing was not associated with clinically significant hypoxia.